ECG features and arrhythmias in takotsubo syndrome

Takotsubo syndrome (TTS) is typically characterized by dynamic electrocardiographic (ECG) repolarization changes, which consist of mild ST-segment elevation on presentation (acute phase) followed by T-wave inversion with QT interval prolongation within 24–48 h after presentation (subacute phase). It is noteworthy that subacute ECG repolarization abnormalities of TTS resemble those of the so-called Wellens’ ECG pattern, which is characterized by transient T-wave inversion in the anterior precordial leads as a result of either myocardial ischaemia or other non-ischaemic conditions, all characterized by a reversible left ventricular dysfunction (‘stunned myocardium’).

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Abstract 4840: Tako-Tsubo Cardiomyopathy without Apical Ballooning - Results of the German Tako-Tsubo Registry

Circulation ◽

10.1161/circ.118.suppl_18.s_947-c ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Anastasios Athanasiadis ◽

Birke Schneider ◽

Johannes Schwab ◽

Uta Gottwald ◽

Ellen Hoffmann ◽

...

Keyword(s):

Coronary Artery ◽

Ejection Fraction ◽

Wall Motion ◽

Apical Ballooning ◽

Left Ventricular ◽

St Segment Elevation ◽

T Wave ◽

Wave Inversion ◽

St Segment ◽

Tako Tsubo Cardiomyopathy

Background : The German tako-tsubo cardiomyopathy (TTC) registry has been initiated to further evaluate this syndrome in a western population. We aimed to assess different patterns of left ventricular involvement in TTC. Methods : Inclusion criteria were: 1) acute chest symptoms, 2) reversible ECG changes (ST-segment elevation±T-wave inversion), 3) reversible left ventricular dysfunction with a wall motion abnormality not corresponding to a single coronary artery territory, 4) no significant coronary artery stenoses. Results : A total of 258 patients (pts) from 33 centers were included with a mean age of 68±12 years. Left ventriculography revealed the typical pattern of apical ballooning in 170 pts (66%) and an atypical mid-ventricular ballooning with normal wall motion of the apical and basal segments in 88 pts (34%). Mean age (68±11 vs 67±13 years) and gender distribution (150 women/20 men vs 80 women/8 men) were similar in both groups. Triggering events were present in 78% of the pts with apical ballooning (35% emotional, 34 physical and 9% combination) and in 75% of the pts with mid-ventricular ballooning (39% emotional, 25% physical and 11% combination). As assessed by left ventriculography, ejection fraction was significantly lower in pts with mid-ventricular ballooning (50±15% vs 45±13%, p=0.006). There was no difference in right ventricular involvement. Creatine kinase and troponin I were comparable in both groups. The ECG on admission showed ST-segment elevation in 87% of pts with apical ballooning and in 78% of pts with mid-ventricular ballooning. T-wave inversion was seen in 70% of the pts irrespective of the TTC variant. A Q-wave was significantly less present in pts with mid-ventricular ballooning (30% vs 16%, p=0.04). The QTc interval during the first 3 days was not different among both groups. Conclusion : A variant form with mid-ventricular ballooning was observed in one third of the pts with TTC. Left ventricular ejection fraction was significantly lower in these pts, although they revealed significantly less Q-waves on the admission ECG. All other parameters were similar and confirm the concept that apical and mid-ventricular ballooning represent two different manifestations of the same syndrome.

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Takotsubo Syndrome: Contemporary Views on the Pathogenesis, Prevalence and Prognosis

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2018-14-4-598-604 ◽

2018 ◽

Vol 14 (4) ◽

pp. 598-604 ◽

Cited By ~ 1

Author(s):

A. S. Shilova ◽

A. O. Shmotkina ◽

A. A. Yafarova ◽

M. Yu. Gilyarov

Keyword(s):

Genetic Predisposition ◽

Randomized Clinical Trials ◽

Myocardial Dysfunction ◽

Specific Treatment ◽

Left Ventricular ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Reversible Left Ventricular Dysfunction

Takotsubo syndrome (TTS) is a reversible left ventricular dysfunction characterized by local apical hypokinesia usually triggered by a physical or emotional stress. According to the last available data TTS may represent 2% of all admissions for acute coronary syndromes. Despite the reliable prevalence, diagnosis of TTS remains difficult. The initial presentation, both clinically and electrocardiographically, is similar to an acute myocardial infarction (AMI). The biomarker profile is also similar, although the peaks of troponin and creatinine kinase levels are lower, and brain natriuretic peptide levels are higher in patients with TTS compared with ST-segment elevation AMI. Modified Mayo diagnostic criteria are the most common for the diagnosis. Pathogenesis of TTS currently is not well understood. Catecholamines appear to play a central role in the pathophysiology of TTS. However, it is conceivable that some people have a genetic predisposition to stress-induced TTS. A genetic predisposition has been suggested based on the few familial TTS cases described. Despite reversible myocardial dysfunction, acute heart failure is the most common complication in the acute phase of TTS. In-hospital mortality rate is comparable to that of ST-segment elevation AMI. There are no randomized clinical trials to support specific treatment recommendations in TTS. It is believed that the tactics of managing patients with TTS hospitalized with suspicion of acute coronary syndrome should comply with the protocol of management of patients with AMI while acute coronary pathology is not excluded.

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Plausible mechanisms of the rapid conversion of ST-segment elevation to T-wave inversion in Takotsubo syndrome

International Journal of Cardiology ◽

10.1016/j.ijcard.2013.08.031 ◽

2013 ◽

Vol 168 (5) ◽

pp. 4593-4595 ◽

Cited By ~ 7

Author(s):

John E. Madias

Keyword(s):

Takotsubo Syndrome ◽

St Segment Elevation ◽

T Wave ◽

Wave Inversion ◽

St Segment ◽

Rapid Conversion

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Electrocardiographic Findings in Takotsubo Cardiomyopathy: ECG Evolution and Its Difference from the ECG of Acute Coronary Syndrome

Clinical Medicine Insights Cardiology ◽

10.4137/cmc.s14086 ◽

2014 ◽

Vol 8 ◽

pp. CMC.S14086 ◽

Cited By ~ 18

Author(s):

June Namgung

Keyword(s):

Acute Coronary Syndrome ◽

Takotsubo Cardiomyopathy ◽

Apical Ballooning ◽

Left Ventricular ◽

Qtc Interval ◽

St Segment Elevation ◽

Coronary Syndrome ◽

T Wave ◽

Wave Inversion ◽

St Segment

Background Electrocardiogram (ECG) manifestations of takotsubo cardiomyopathy (TC) produce ST-segment elevation or T-wave inversion, mimicking acute coronary syndrome (ACS). We describe the ECG manifestation of TC, including ECG evolution, and its different points from ACS. Methods We studied 37 consecutive patients (age 67 ± 15 years, range 23-89, M:F = 12:25) from March 2004 to November 2012 with a diagnosis of TC who were proven to have apical ballooning on echocardiography or left ventricular angiography and normal coronary artery. We analyzed their standard 12-lead ECGs, including rate, PR interval, QRS duration, corrected QT (QTc) interval, ECG evolutions, and arrhythmia events. Results Two common ECG findings in TC were ST-segment elevation (n = 13, 35%) and T inversion (n = 24, 65%), mostly in the precordial leads. After ST-segment resolution, in a few days (3.5 days), diffuse and often deep T-wave inversion developed. Eight patients (22%) had transient Q-waves lasting a few days in precordial leads. No reciprocal ST-segment depression was noted. T-wave inversion continued for several months. QT prolongation (>440 milliseconds) was observed in 37 patients (97%). There were no significant life-threatening arrhythmias except atrial fibrillation (n = 6, 16%). Conclusion There are distinct differences between the ECGs of TC and ACS. These differences will help to differentiate TC from ACS.

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Cardiac Rupture—The Most Serious Complication of Takotsubo Syndrome: A Series of Five Cases and a Systematic Review

Journal of Clinical Medicine ◽

10.3390/jcm10051066 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1066

Author(s):

Małgorzata Zalewska-Adamiec ◽

Hanna Bachórzewska-Gajewska ◽

Sławomir Dobrzycki

Keyword(s):

Female Gender ◽

Left Ventricular ◽

Cardiac Rupture ◽

Control Group ◽

Mechanical Complication ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Glucose Levels ◽

Risk Of Death ◽

St Segment

Background: The most serious complication of the acute Takotsubo phase is a myocardial perforation, which is rare, but it usually results in the death of the patient. Methods: In the years 2008–2020, 265 patients were added to the Podlasie Takotsubo Registry. Cardiac rupture was observed in five patients (1.89%), referred to as the Takotsubo syndrome with complications of cardiac rupture (TS+CR) group. The control group consisted of 50 consecutive patients with uncomplicated TS. The diagnosis of TS was based on the Mayo Clinic Criteria. Results: Cardiac rupture was observed in women with TS aged 74–88 years. Patients with TS and CR were older (82.20 vs. 64.84; p = 0.011), than the control group, and had higher troponin, creatine kinase, aspartate aminotransferase, and blood glucose levels (168.40 vs. 120.67; p = 0.010). The TS+CR group demonstrated a higher heart rate (95.75 vs. 68.38; p < 0.0001) and the Global Registry of Acute Coronary Events (GRACE) scores (186.20 vs. 121.24; p < 0.0001) than the control group. In patients with CR, ST segment elevation was recorded significantly more often in the III, V4, V5 and V6 leads. Left ventricular free wall rupture was noted in four patients, and in one case, rupture of the ventricular septum. In a multivariate logistic regression, the factors that increase the risk of CR in TS were high GRACE scores, and the presence of ST segment elevation in lead III. Conclusions: Cardiac rupture in TS is rare but is the most severe mechanical complication and is associated with a very high risk of death. The main risk factors for left ventricular perforation are female gender, older age, a higher concentration of cardiac enzymes, higher GRACE scores, and ST elevations shown using electrocardiogram (ECG).

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Midventricular takotsubo syndrome: different dyskinesia location leading to a different electrocardiogram?

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.123 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

M Padilla Lopez ◽

A Duran Cambra ◽

M Vidal Burdeus ◽

L Rodriguez Sotelo ◽

J Sanchez Vega ◽

...

Keyword(s):

Acute Phase ◽

Clinical Symptoms ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Funding Sources ◽

Wave Inversion ◽

St Segment ◽

Electrocardiogram Ecg ◽

Study Inclusion

Abstract Funding Acknowledgements Type of funding sources: None. Background Takotsubo syndrome (TKS) is characterized by the appearance of apical reversible dyskinesia in its typical form. Electrocardiogram (ECG) in the acute phase (<12 from symptom onset) generally shows anterior ST segment elevation. Nonetheless, other atypical forms of TKS have been described depending on the location of the dyskinetic segments, such as, mid-ventricular, basal and focal forms. Considering the different segments involved in these atypical forms, it seems reasonable to consider that ST changes in acute phase ECG could be different. Purpose To compare ECG in the acute phase of typical TKS versus mid-ventricular TKS, as it was the more frequent form of atypical TKS in our registry. Methods Patients included in the prospective TKS registry of our center according to the Mayo Clinic diagnostic criteria, with the first ECG performed less than 12 hours from the symptoms onset were reviewed. All cardiac left ventriculographies were reviewed to ensure a correct classification of the different types of TKS. Results A total of 297 patients were included in our local registry. 80 patients met our study inclusion criteria. 56 ECGs of typical apical TKS were compared to 24 ECGs of atypical midventricular TKS. There were no differences between the baseline characteristics in both groups, except for mid-ventricular TKS, that was more frequently triggered by physical stressor. Regarding the ECG analysis, the main difference found in our serie was related to ST-segment deviation (Table 1). While ST-segment elevation was more common in typical TKS than in atypical TKS (73% vs 50%), ST-segment depression (generally in inferior leads) was observed in 54% of patients with atypical TKS and in no patient with typical TKS (figure 1). Conclusion The different location of dyskinesia between typical TKS and mid-ventricular TKS is associated to significant differences in the ECG obtained in the first hours after the onset of the clinical symptoms. The presence of ST-segment depression is highly suggestive of mid-ventricular TKS. ECG characteristicsTypical (n = 56)Midventricular (n = 24)pSTe > 1mm, no (%)41 (73)12 (50)0,044STd >0,5 mm, no (%)013 (54)< 0,001T wave inversion, no (%)12 (21)4 (17)0,626Q wave, no (%)22 ( 39)12 (50)0,374cQT, mean (SD)445 (54)438 (37)0,578QRS low voltages*, n (%)9 ( 16)1 (4)0,328STe ST-segment elevation, STd: ST-segment depression, cQT: corrected QT interval *Voltages <5mm in all limb leads or <10mm in all precordial leads Abstract Figure. 12-lead ECG and left ventriculography

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The mortal cause of sudden ECG changes in patients with chronic aortic insufficiency: Aortic dissection

Interventional Medicine and Applied Science ◽

10.1556/1646.10.2018.50 ◽

2019 ◽

Vol 11 (1) ◽

pp. 68-70

Author(s):

Mahmut Yesin ◽

Turgut Karabağ ◽

Macit Kalçık ◽

Süleyman Karakoyun ◽

Metin Çağdaş ◽

...

Keyword(s):

Risk Factors ◽

Aortic Dissection ◽

Signs And Symptoms ◽

Aortic Insufficiency ◽

Ecg Changes ◽

St Segment Elevation ◽

T Wave ◽

Wave Inversion ◽

St Segment ◽

High Index Of Suspicion

The symptoms of aortic dissection (AD) may be highly variable and may mimic other much common conditions. Thus, a high index of suspicion should be maintaned, especially when the risk factors for AD are present or signs and symptoms suggest this possibility. However, sometimes AD may be asymptomatic or progression may be subclinical. Various electrocardiographical (ECG) changes may be seen in AD patients such as ST segment elevation in aVR as well as ST segment depression and T-wave inversion. In this case report, we reported a patient with acute AD whose ECG revealed ST segment elevation in aVR lead in addition to diffuse ST segment depression in other leads.

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Independent Predictors of One-Month Mortality in Patients with Intracranial Hemorrhage; a Cohort study

Frontiers in Emergency Medicine ◽

10.18502/fem.v5i4.6690 ◽

2021 ◽

Author(s):

Hamid Kariman ◽

Behnam Babadi ◽

Masomeh Raofi ◽

Saeed Safari

Keyword(s):

Cohort Study ◽

Basal Ganglia ◽

Blood Sugar ◽

Intracranial Hemorrhage ◽

Left Ventricular ◽

St Segment Elevation ◽

Wave Inversion ◽

St Segment ◽

One Year ◽

Ecg Abnormalities

Introduction: Predicting the outcome is one of the most frequent and important issues when approaching patients with intracranial hemorrhage (ICH). Objective: This study aimed to evaluate the correlation of SUSPEKT score variables plus electrocardiogram (ECG) abnormalities with one-month mortality of patients with ICH presenting to emergency department (ED). Methods: In this cohort study, adult patients presenting to the EDs of three educational hospitals, during one year, were followed and their one-month mortality rate as well as independent predictors of outcome among the variables of SUSPEKT score plus electrocardiography findings were evaluated. Results: One hundred seventy-seven patients with the mean age of 63.07±14.89 years were studied (59.9%). The most common locations of intra-parenchymal hemorrhage were basal ganglia (53.7%) and cortex (36.2%). Ninety-two (52.0%) of cases had at least one ECG abnormality. The most frequent ECG abnormalities were ST segment depression (20.3%), T wave inversion (16.4%), and left ventricular hypertrophy (14.7%). Thirty (16.9%) cases died during the 30-day follow-up. Survived and non-survived cases were significantly different regarding the location of intra-parenchymal hemorrhage (p < 0.0001), presence of intraventricular hemorrhage (IVH) (p = 0.007), ST segment elevation (p < 0.0001), bradycardia (p < 0.0001), tachycardia (p < 0.0001), arterial fibrillation (p < 0.0001), blood sugar (p = 0.044), and serum level of potassium (p = 0.022). Conclusions: The location of hemorrhage (basal ganglia), higher blood sugar, and presence of ECG abnormalities (ST segment elevation, tachycardia, bradycardia, atrial fibrillation) were among the independent predictors of one-month mortality of ICH patients in this study.

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Abstract 3268: Ethnic Differences in the 12 Lead -EKG - Relevance to the Cardiovascular Evaluation for Hypertrophic Cardiomyopathy in Athletes

Circulation ◽

10.1161/circ.118.suppl_18.s_1121-b ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

John Rawlins ◽

Michael Papadakis ◽

Carey Edwards ◽

Sandeep Basavarajaiah ◽

Sanjay Sharma

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Cardiac Mri ◽

Left Ventricular ◽

Exercise Stress ◽

Black Athletes ◽

St Segment Elevation ◽

T Wave ◽

St Segment ◽

Phenotypic Features ◽

Cardiovascular Evaluation

Introduction Cardiac adaptation to intense physical exercise is associated with physiological increases in cardiac dimensions that are reflected on the EKG. The EKG changes in Caucasian athletes (WA) are established, however, there is a paucity of data in black athletes (BA) who constitute an increasing proportion of elite athletes in Western countries. We sought to identify differences (if any) in EKG characteristics between BA and WA participating in similar sporting disciplines. Methods Between 2007– 8, 222 nationally ranked male BA aged 14 –35 and 496 WA of similar age, size and range of sporting disciplines underwent a EKG and standard 2-D echocardiography. All athletes with a left ventricular wall thickness > 12mm and deep T wave inversion (> −0.2 mV) underwent Holter monitor, exercise stress test, and cardiac MRI to exclude phenotypic features of hypertrophic cardiomyopathy (HCM). Results Black athletes had a greater prevalence of voltage criteria for left ventricular hypertrophy (LVH) (57% vs 42%; p < 0.005), ST segment elevation (76% vs 33%; p < 0.001) and T wave inversions (25% vs 4%; p < 0.001) compared with WA. ST segment elevation in all athletes was confined to the anterior precordial leads but 50% BA exhibited a unique convex ST segment elevation pattern that was absent in WA. There was no correlation between T wave inversions and LVH at echocardiography or cardiac MRI. Indeed none of the BA with T wave inversions displayed any phenotypic features of HCM. Conclusion Black athletes exhibit different adaptive responses to exercise than WA. Deep T wave inversions and convex ST segment elevation are common in BA, with or without LVH and may overlap with HCM. These results have significant implications during pre-participation screening. There is the potential risk of generating a false positive diagnosis of HCM and lead to unnecessary exclusion from competitive sport, if data derived from WA, used to identify an abnormal EKG, is incorrectly extrapolated to BA.

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